HomeMy WebLinkAboutMiscellaneous - 267 MASSACHUSETTS AVENUE 4/30/201821Z
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ..............................
has permission to perform .121
......... ........................
-e2--
plumbing in the buildings of ....... ...........................
at (7:'). ............. North Andover, Mass.
Fed'—?4. Lic. No.
............
INSPECTOR
Check PLUMIBIV'
8 5:02
MASSACHUSETI'S UNIFORM "PLICATION FOR PERMIT TO DO PLUMBING
gype or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location f2 a 7 ,Yf �-,r
Owner
New [:] . . , Renovation Ej Replacement 0
FTYTFTRlPQ
c,2— 2
Date
Permit
Amount 3 e,
Plans Submitted Yes [—] . No
(Print or type)
Installing Company Name /0,//
-- 6 0 3 -7 Y Z- Z/ & - �/z
Check one: Certificate
0 Corp.
Partner.
Fimi/Co.
Name of Licensed Plumber: j �- V q '-. S , 4-, IC14,141,1,5
Insurance Coverage: Indicate the type of insurance coverage by the appropriate box:
Liability in� policy ID Other type of indemnity Bond
Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
signature
, Owner Agent rl
I hereby certify that all of the details and information I have submitted (or entered) in above application are I true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massaoh etts S bi Code and Chapter 142 of the General Laws.
By: 1,0^ 2�
SigZe of Eicensw F111111ber
Title ype of Plurribing License
lCity/Town /07z-/
1 APPROVED (OFFICE USE ONLY License Numm Master El Journeyman El
V,
The Commonwealth Of Massachusetts
Department Of Lndustrial Accidents
Office of Lnvestigations
,.0,00 Washington Street
Boston, M4 02111
www-massgov1dia
Workers' Compensation Insurance Affidavit: Buflders/Contractors/Electricians/Plumbers
Name (Business/Organizafion/Individual): - -4 ,, �;
Address:
ev
City/State/Zip:_)!9/,,1 �c,,l "03i -l -r Phone#: &"o.3
Are you an employer? Check the appropriate boxi
LEI I am a employer with 4. 1 am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. 1 am a sole proprietor or partner- listed on the attached sbep.t I
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
F71 am a homeowner doing all work
myself [No workers, comp.
insurance required.] t
*A nX, fb L _ — - I I -
These sub -contractors have
workers' comp. insurance.
We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
c0mP- insurance required.]
Type of project (required):
6. F1 New construction
7. 0 Remodeling
8. F Demolition
9- 7 Building addition
10. 0 Electrical repairs or additions
I I - 0 Plumb mig repairs or additions
12.0 Roof repairs
13.0 Other
-1 IU- VUL LFIC NUCUO�. DL�101L�l ShAvIrIng t; * i
,eif
WO,
V
_,ers
MOn Policy mformat,
Homeowners who submit this affidavit indicating they are doing aN work and then hire outside contractors must submit a new affidavit indicating such.
�Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers, COMP. Policy information,
am an employer that is providing workers' compensation M'Szirance for my employees. Below is the policy andiob site
informadom
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of M . GL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a c py of this sta m t may be for . warded to the Office of
Investigations of the DIA for insurance coverage verification. 0 te en
I do hereby certift under the , s andpenalties ofperjury that the information provided above is true and correct
, 11 __V_ — – le:
Phone #: 3.-,z �/./'/z
1[7O��ffi;cTial use only. Do not write in this area, to be completed by city or I town official
City or Town:
Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitYrrown Clerk 4. Electrical Inspector 5. Plumbing
6. Other . Inspector
Contact Person:
Phone #:
on
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including t1ae legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returne to the city or to-�,m that the application for the perinit license is being requested, not the Department of
d or
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
ofthe affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston� MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 www.mass..gov/dia
74
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
'111Z�NU5� �
This certifies that ... ... .................
has permission to perform
plumbing in the buildings of ....... .... ..... ................
0
lat.7. .� ........ orth Andover, Mass.
Fee�-//7. Lic. N/24—A)II.
PLUMBINd INSPECTOR
Check # /�� �/' I,//
5 c,,,4 8
#a
MASSACHUSETTS UNIFORM
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location c;�9-'7 lhl�e-
New
Renovation
of
TION FOR PERMIT TO DO PLUMBIN(
U
ce-
Date
Permit
Amount
Replacement Plans Submitted Yes. El No El
FIXTURES
=3
C
C C
RASMM
M Hi"
MR" . . . ...................
3M H-"
4MBi"
5MIL"
6M B-"
7M11"
(Print or type) Check one: Certificate
Installing Company Name 1:1 Corp
Address �,t S A ri Partner.
(T) t
Business Telephone ?!5 —05 -?0 Finn/Co.
Name of Licensed Plumber: &FELtL-2
Insurance Coverage: Indicate the type of insurance coverage by checldng the appropriate box:
Liability insurance policy Other type of indemnity Bond
El
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three irtsurftce
� %/*,
Signatdr't owner Agent
9 1� El
I herevy certify that all of the details and information I have submitted (or entered) . in
,*ove application are true and accurate to the
best of my knowledge and that all plumbing work and installati Imed e mit Issued for this application will be in
f the Massa . 10 e4' e er 142 of the General Laws.
compliance with all pertinent provisions o Lts S Z�Cand
C 3t;� 1FPt
Title
City/Town
APPROVED (OFFICE USE ONLY
Type df Pl bing License'
/7 SV 7
License lNum5er - — Master
f '�x '�
Journeyman P�
4
i
9
V
Location M A SS A
No.
Date ( � (� Cl?:.
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
MU Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
,# -I Q- �L
Check #
16.9 u 2
I MrSaw
-)MA (
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT,
APPLICATION TO CONSTRUCT REPAI$ RENOVATf MOLISH A ONE OR TWO FAMILY DWELLING
In R, OR DE
2 -cm ENRON=
BUILDING PEPMT NUMBER: 3 Lj DATE ISSUED: /J-/8
SIGNATURE:
Building Commissioner/12Swor of Buildings Date
SECTION 1- SITE INFORMATION I
1. 1 Property Address:
1.2 Assessors Map and Parcel
N11p Num5er
Number:
X3
Parcel Number
1.3 Zoning Information:
Zoning Diax�dt Proposed Use
1.4 Property Dimensions:
Lot Area (sf)
Frontage (ft)
1.6 BUILLDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required
Provided
Required
Provided
1
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public 0 Private 0 Zone Outside Flood Zone 0
1.8
Municipal
SeweMe Disposal System:
0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHW/AUTHORIZED AGENT Historic District: Yes No_
2.1 Owner of Record
oti�j
Name (Print) Address for Service
6�� )Ls—v S—(ag
Sig*re tl — V Telephone
2.2 Owner of Record:
Nalmie Print Address for Service:
§:ignli�re Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable 0
Dr—
�TCIT(,N 0.
Licensed Constru&fon Supervisor: 55 233
License Number
'zos A/C. 140)VVfk,;11
An, -7)9 52/ 1�
Expiration Date
sigvtufe I Telephone
3.2 Reetstered Home Improvement Contractor Not Applicable 0
CompaAy Name
Registration Number
Address
Expiration Date
Signature Telephone
89
M
X
0
Lo
Z16
0
z
M
90
0
"n
r
M
z
G)
SECTION 4 - WORKERS COMPENSATION (MG.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... Z No ....... 0
Failure to provide this affidavit will result
SECTION 5 Description o Proposed Work (check applicable) — I fAherations(s) )Q Addition 0
New Construction 0 Existing Building Repair(s) 0
Accessory Bldg. 0 Demolition 11 Other 11 Specify
Brief Description of Proposed Work:
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I . I I .
'Y q 1,
Item Estimated Cost (Dollar) to be
0 pr: v
w
Completed by permit applicant
1. Building
(a) Building Permit Fee
3 000
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
-3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical (HVAC)
-5 Fire Protection
-6 Total (1+2+3+4+5) C)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Z> f+/,) Ir 6HIE&d as Owner/Authorized Agent of subject property
Hereby authorize qUl A �0(,A to act on
y a , a rs re v to work authorized by this building permit application
. 111/& to
_Sign#reof22Yer_ Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Printrame
63
Sign0w� of OvW4Age_nt__CT_ Date
NO. OF STORIES SIZE
-BASEMENT OR SLAB
-SIZE OF FLOOR TIMBERS I sr 2 ND 3fw
-SPAN
DIMENSIONS OF SILLS
-DIMENSIONS OF POSTS
-DIMENSIONS OF GIRDERS
-HEIGHT OF FOUNDATION THICKNESS
-SIZE OF FOOTING X
MATERIAL OF CHRVINEY
-IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of IVIGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by IVIGL
c 11, S 150 A.
The debris will be disposed of in:
C 4 ('0 V44 t 0,&r S Crd ( CA -
(Location of Facility)
A
ig6lfitur"f Permit Applicant
11OU
I ( Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
— �..j
Z
(0 ��o
0) io
4;Z- 'Q
0 z
0 ...c?,
7
(1), 1 7-
-4) 'RW
co
LO
4 4)
20
0)
F- T
< >
14�
W
C
00-
F
w D
co
E
'o
Z
Cl)
co
z o
C,',4
U-)
— �..j
Z
(0 ��o
0) io
4;Z- 'Q
0 z
0 ...c?,
7
(1), 1 7-
-4) 'RW
0
4 4)
— �..j
Z
0
The Commonwealth of Massachusetts
Department of Industilal Accidents
Office of Investigations
Boston, Mass. 02111
Workers� Compensation Insurance Affidavit
Name Please Print
Name: I C T-Tfte t-4 L"
Location: Z(_)
Phone SZ/
I am a homeowner'performing all work myself.
F-1
I am a sole proprietor and have no one worldng in arry capadty'
I am an employer providing workers! compensation for nTy employees worldng on this job.
C i hr
FalkwetoseemecoverVe as reqWredunderSec0on25AorA4M 1W can1eadto,#*kr;=j6w cfc*dndpenajjt�—S&-7Gt , toSIA
.&fteud,t,S.,.j
anWor one yeW kqxbonnmt-as vm[Las A
-btbalc= J1W-dA$1WM)-ajdayAqa1mtM-_
undemtand that a copy df fts statement may b� ftwarded to the Office of Investigations of ft 6A fbr cowwage V"H;cWCWi
do hereby cw* wx1ar Me pam and penafts qtpe,70YP& Me mkmmffw provided above is &w and cmect
Signature OJlAw. oD
Date
Print name Mga/z
_Pbonel(j2'�)STZ/ Well
Quinlan & Rand
IBUHLDERS
34 Trinity Court
North Andover, MA 01845
Phone 508-682-1570 - 508-521-4196
Pro rjos a I Paqe No. of Paliales
PROPOSAL SUBMITTED TO
,01,
0 6-o
PHONE
DATE
STREET
JOB NAME
R67
CITY, STATE AND ZIP CPDE
A,4oizey Ac.
JOB LOCATION
WoHh to/f
ARCHITECT
DATE OF PLANS
08 PONE
7 Q 5g,qFjC-
We hereby propose to furnish materials and labor necessary for the completion of�
0% 1 1 A
-Ploor ?0"S,/r /a
71- 6,
U)
m
m
X
m
4
m
X
CA
m
CA
CP
m
CO) Cl)
"0 0
CD
0 Z co)
F,* 0 -0 .
CD
CL Cl)
=r
cm a. CO)
C-)
CD
0
CD
CL
r.r
CD
T
CD 0 CD
w w a.
CD cop)
CD
CL CO)
CD
F
CA
10 z
CD
CD
CD
0 LA. C')
=r 7R
CL
to 0
CD
CD
co
R S9
n CD
CA
r)
ca a,
CL
CO) CD cr to
c a
CA
CA
Cc.D
Cc,
to
co
0
gift
CD
CA)
CDOR
a-00
db =
ncl)
r 0 CM
C 0
,
C)
CD:
- =11-1 -,.I
C/)
0
pq-
ro
t:�
rb
0
cr to
"
-z
Cl
tTj
�o
0
C:
So E -Lo 10
:* 0 CD
CO2
C')
(n
rD
co
CA Ff CL C2
m
C)
m
:�
z
CD _0 C
==
=
C)
C/)
(D
r),
C/)
-e
0
VL
1-1
7�
;;,
(11
=r CL CL 0=
=r
=r
CD
CD go
CD
=r CD: a
w
0
0 LA. C')
=r 7R
CL
to 0
CD
CD
co
R S9
n CD
CA
r)
ca a,
CL
CO) CD cr to
c a
CA
CA
Cc.D
Cc,
to
co
0
gift
CD
CA)
CDOR
a-00
db =
ncl)
r 0 CM
C 0
,
C)
CD:
- =11-1 -,.I
C/)
0
pq-
ro
t:�
rb
(1)
"
-z
Cl
tTj
�o
0
C:
III
(n
rD
m
0
00
PZI
0
C)
m
:�
n
�:r
r:
aq
X
r-
�j
CL
w
C!
0*
C)
C/)
(D
r),
C/)
-e
0
VL
1-1
7�
;;,
(11
M
C)
I
&"Wm
Ul
m
x
I
7 �) 7
z x
z
< z
Ci
z
Q)
/IQS
7s
7—
z
\J)
z
V)
F -
7K
7m
\J) >
>
:<
7 X
z
ZZ ��\
ZONJINICA 5EfL3ACr,
12'-0'' (VIF)
z
PPIOPE-Pli-Y LINE-:
N ---\ Q�
(�
Z
Z
z
j Ts
7s
7�
/75
-7,KS
\J-1
Q)
71�s
m
x
I
7 �) 7
z x
z
< z
Ci
z
Q)
/IQS
7s
7—
z
\J)
z
V)
F -
7K
7m
\J) >
>
:<
7 X
z
ZZ ��\
ZONJINICA 5EfL3ACr,
12'-0'' (VIF)
z
PPIOPE-Pli-Y LINE-:
N ---\ Q�
(�
Z
Z
z
j Ts
7s
7�
-41
FIX
I
SO
ME
5- 0 P F- P
51-OPEP CL -6.
FA,
r --o
yl
5L-op�p CL
73Z
NO
Co
V7 T7
SO
ME
5- 0 P F- P
51-OPEP CL -6.
FA,
r --o
yl
5L-op�p CL
73Z
NO
75 \J)
77
"ll
71�s
I
�z
z
5: --O-p -F� L-? C -L- C -A,
>
<
75 >
75
75
P, z
-A
4t
K5
_7
Q)
75
3:
7s
QO
71�
-75
-----
7-55 7orv-7-
—
77-
75
QN
Q�\
z
5: --O-p -F� L-? C -L- C -A,
>
<
75 >
75
75
P, z
-A
K5
_7
Q)
75
3:
7s
QO
71�
z
5: --O-p -F� L-? C -L- C -A,
> 75
7s
Z <
>
>
<
75 >
75
75
P, z
-A
z
7s
QO
-----
7-55 7orv-7-
> 75
7s
Z <
>
75 >
75
75
P, z
-A
z
> 75
7s
Z <
>
z z
> C)
'TS
77
77
Z
7s
-----
7-55 7orv-7-
z z
> C)
'TS
77
77
Z
..........
X 7—
r— — -T—
I — —
5�F 5�CnON MAW
z
J)
>
>
z
z z
/75
K5
73
7
I- — -- — -- — -- — F rl-o- p —r_� Fl -T -Y —I- I N- r-:� —
3: `� C) 7
(:� Z
zm
> -77 -Z m z >
FS m
< < 1: >
<
Mm Q0 T\N
,;�3 > M T
z
Q�
>
z
Q�
F -
x
<
> N -7
> M
03
21
�7
x
z
71
7
Iz
>
Z
m 71�
1 7
31
C3
Rx
z
Z Z
p
<
�7
> z
v z
z
<
-It — — — — — — — — — — —
— — — — — — — — — — — —
i�T
> z
>
= 7
zc--,�x .
x u L- Z
Z 0
\ji
Ls
M -A z
> z
C� Cs
cm
77 x
77 /'Z
715
/M
77
z
L�
I
71
m
z
2
7 m t,3;� 2 �L �
P, x t-� — z
> C') 7
Z"*
z
z
ZN
/KS
g
77
m
1�3
m
z
Q0
Z
-
(� z
>
_77
75
z
0
F
z Z
Z
-
(� z
>
z
0
F
z Z
>
>
Z�
m >
z
z z
z
-77
z
7s
7S
>
—7s
>
<:
77S
Q�\
Z
-
(� z
>
z
0
F
z Z
>
>
Z�
m >
z
z z
z
z
7S
1-\
71
z
I
Z:
K5
Ts
2
K33
Location 0260 )1 '1 A S k� U --S
No. �3Q (o
Date I ;t,- it,, - 0 2,
,4001,rh
TOWN OF NORTH ANDOVER
0
Certificate Occupancy $
of
'0.,40. 11
CHU
Building/Frame Permit Fee $ �� 0
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check # n (:), 1,8
16074
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUII,DING PERNUT NUMBER: DATE ISSUED:
SIGNATURE:
11
Building Commissioner/I tor of Buildings Date
SECTION I- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
1(0
Map Number Parcel Number
C�? to
1.3 Zoning Information:
Zoning Dii;ic-t Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (ft)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Re�red Provided
ReqWred Provided
—+
1-54)
T
1.7 Water Supply M.G.L.C.40 1.5. Flood Zone Information:
Public 0 Private 0 Zone Outside Flood Zone 0
L8 . Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
F-Cpq-rd � % 6, 1 C C,
Licensed Construction Supervisor:
o ve A4
Address
Signature Telephone
Not Applicable 0
0
License Number
Expir6tion Date
3.2 Registered Home Improvement Contractor
Not Applicable 0
sc�
Company Name I
Registration Number
Address lo
Expirati6n Da(e
Sienature Telephone
0
z
M
90
0
M
z
Q
IN
a
I SECTION 4 - WORKERS COMPENSATION (NLG.L C 152 § 25c(6) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check
spplicable)
New Construction 0
Existing Building 0
Repair(s) 0
Alterations(s) 0
Addition 0
Accessory Bldg. 0
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
ul�
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Itern
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFIC LAL USE ONLY
I . Building
4, S-0 0
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
Plumbing
Building Permit fee (a) x (b)
-3
4 Mechanical (HVAC)
Fire Protection
-5
Total (1+2+3+4+5)
Check Number
-6
SECTION 7aqWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AOtNT OR.CALXA�TOR APPLIES FOR BUILDING PERMIT
-
lasOwner uthorizedAgent -subject property
Hereby authorize- to act on
My behalf, in all matters relative to work authorized by this building permit application.
of Owner Date
-Signature
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Signature of Owner/A ent Date
"Mm I- N
OF STORIES SIZE
-NO.
OR SLAB
-BASEMENT
IST ND RD
SIZE OF FLOOR TIMBERS 2 3
-SPAN
OF SILLS
_DIM[ENSIONS
OF POSTS
-DIMENSIONS
DIMENSIONS OF GIRDERS
OF FOUNDATION THICKNESS
-HEIGHT
OF FOOTING X
-SIZE
OF CHEVINEY
-MATERIAL
BUILDING ON SOLID OR FILLED LAND
-IS
—IS BUILDING CONNECTED TO NATURAL GAS LINE
A
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 k
The debris will be disposed of in:
(1-6cation of Facility)
Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through.the Office of the Building Inspector
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Irk CS 034317
Number
Birthdate: 04M611952
G4/161,2004 Tr. no- 22799
Expires'.
Restricted, 00
RICHARD L GILES
240 ANDOVER ST Administrator
N ANDOVER, MA 01845
,( ?1,(, .0- 1. 1 ( CA) 0 -2-
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
Name Please Print
Name: P( A0 Id
F-1 I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
F-1 I am an employer providing workers' compensation for my employees working on this job.
ComDanv name:
Address
cibc Phone#.
Insurance. Co. Policv #
Company name:
Address
Cily: Phone #:
Insurance Go. Policv #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00
andlor one years' imprisonment-as-wefl-as-cMi,penafties in-the-fam da-STOPWORKORDER-and-a fine of -($10-00)-a -day..againstme, I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
V
do hereby certify undede pains and penalties _qf pedury that the inforrnation provided above is true and correct.
/ -� h & lo
>
Print name �1 61 Phone
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/licensing
El Building Dept
E]Check ff immediate response is required .0 Licensing Board
[:] Selectman's Office
Contact person: Phone #.- r-1 Health Department
Ei Other
5 1
Cl)
m
m
m
m
m
m
C/)
m
U)
0
m
b
CO)
CD
Cl) z
P-* C*
CD
CL
-00
CD
CL
Cr
CD 0
F-w--vM w . I
a: C2
CD
CO)
"0
CD
CO)
co
CA
CO)
ki-I
a)
Cl)
CD
CD
Ma
"It
CD
a
CA
CD
CO2
1
CD
a
CD
dc
CD
OC to *,o -0 = -4
=r-, 0 w
.C,o 0 cr C*
0 :5. a =
=t CL 0 CD
— CD n -1
0 CL C.) M
CD -0 c =
z =ro CA
M to — CA
CD go 012
-B. CD
CD -Ic CA
=CD
CD
W.
0
Z :S C')
0 !j C')
0 CD -
=r 121 No,
to 0
c=L 4-
C/) C=Dr CEO
CD
cn
CD CD
c OR
n ca
CD
0 a,
cn 0
cn CD
fW 0
M CD
CD
CD
cn
t3
C)'COD
CD:
0
CD
C/)
C/) CA
CD
00 CD
Ca -R.
CO)
0=
CD:
LW
cn
0
cn
rb
'TJ
M
071
--
�j
cn
rb
91
Ag
r?4
Ix
PC
0
r:
OQ
�x
n
00
'T'
�:l
CL
C)
2
cn
cn
F
cf)
rb
0
r -L
tz
ommq
0
7, 71. 5 eo 7& Wh 7t W5,4Z 7,;� 0 9 7X4
V040 --C 4 Pd&� S4�Y#
BOARD OF FIRE PREVENTION REGULA
APPLICATION FOR PERMIJTO
All work to be performed in accordance h the
(Please Print in ink or type all information)
Town of North Andover 'AV
The undersigned applies for a permit to perform the electrical work described below.
Location (
Owner or
Official Use Only
Permit No. �6-6
wmg??s
527 CMR 12:00 Occupancy & Fee Checked.N6—z
RFORM ELECTRICAL WORK
3achusetts Electrical Code 527 CMR 12:00
Date
To the lnspeetor�'of ftes:
Owner's Address
Is this permit in conjunction with a building permit Yes 0 No V --,"(Check Appropriate Box)
Purpose of Building 14 Utility Authorization No. 42 /01?
E)dsting Service__/OQ__Amps _/;b._./,'2Y'P_Voits Overhead Undgmd 0 No. of Meters
New Service IV Undgmd 0 No. of Meters
– V_AmpsAWQVVofts Overhead 91--�
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA
Above 9 In 0
No. of Lighting Fbdures Swimming Pool gmd 9 gmd 0 Generators KVA
No. of Emergency Lighting
—Mn-of-Receutacles Outlets No. of Oil Burners Battery Units
Date ... ... CAJ.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......
has Permission to perform
............ .........
wiring in the building of
at ... g�24�
...... 7
............................... .........
Fee � .................... Lic. No . ..............
Check # _1&.5-ly
5099
(Signature of Owner or Agent)
.j ........... ...... . NorthAmdover, Mass.
................
EALARMS No.ofZone
of Detection and
atinq Devices
No. of Sounding Devices
NoJ of Self Contained
Detection/Sounding Devices
a Municipal 0 Other
Low Voltage
= NO -
verage by checking the appropriate box.
Date)
UC. NO.--d/ff &K=
LIC. NO.
tantial equivalent as required by Massachusefts
(Please Check one)
erg-/
FEE $
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name:
Location:
Ci1y Phone
F� am a homeowner performing all work myself.
F-1 I am a sole proprietor and have no one working in any capacity
F] I am an employer providing. workers! compensation for my employees working on this job.
Company name:
Address
City: Phone #:
Insurance Co. Policv
Compgny-name:
Address
Ci!y: Phone #7
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00
andlor one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify under the pains and Penalties of pegury that the information provided above is true and con-ect
Signature.
Print name Phone #
Official use only do not write in this area to be completed by city or town official' C] Building Dept
E]Check if immediate response is required Building Dept E] Licensing Board
[] Selectman's Office
Contact person 7 Phone #.- F1 Health Department
Other
FORM WORKMAN'S COMPENSATION
WF�.
&""- "? - 'f '71
Date.....................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
.. ......... .........
.........
has permission for ga?i.7,ajlation
in the buildings of ...... *,(-- �-- 6
at - - - �- .... ..... ;�
Fee4,5-.0- . Lic. No. /A ".7. .
Check # 12,;' �1,3
4753
XNhAn.dover, Mass,
?WE eM;aWW5W?W 07 X4
VO4V-04 4 PIA�l S4W#
BOARD OF FIRE PREVENTION REGULA
APPLICATION FOR PERMIJTO
All work to be performed in accordance h the
(Please Print in ink or t)W all information)
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Official Use Only
Permit No. �5 26 59
Occupancy & Fee Checked
527 CMR 12:00
4 ELECTRICAL WORK
Electrical Code 527 CMR 12:00
Date �3 / 2 SVA
To the Inspedor-of Wif. as:
Location (Street & Number SS
Owner or Tenant "Wo, r1N
Owner's Address-5Q� YA-9--
Is this permit in conjunction with a building permit Yes a No re -**,(C -heck Appropriate Box)
Purpose of Building 14 ,-�A-sL- Utility Authorization No. lleaoll
Existing Service ----J Amp� F foa� 4 Overhead Undgmd 0 No. of Meters
j2D I Id Voits
New Service Amps
_4WVVoits Overhead Undgmd a No. of Meters
2
Number of Feeders and Ampacity.
Location and Nature of Proposed Electrical Work
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Lam
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO
have submitted valid proof of same to the Office YES = NO - If you have checked YES please indicate tile " o
Icoverage by checking the appropriate box.
INSURANCE - BOND - OTHER - (PleaseSpecify) '71-eAvel Ere. dS
Estimated Valueof. Electrical Work$. / (Expiration Date)
Work to Start Inspection Date Resquested -Rough Final
Signed under the P nalt' s of perj
FIRM NA =r- ;Fye -,t 4-4-) C -CL a-,,, -L-2,-Ir rit Imr I If, fin
Licensee
Address56 o?-�—Y-kz AW A)
^11thloole I-- — 0 . A.- — �
: am re , e - n S U01-� WOUL 11dVe IFIC IFISLIFRI
General Laws. And that my signature on this permit application waives this requirement.
nce coverage or ITS SUDsTanuai equivarem: as requirea ny Massachusetts
Owner Agent (Please Check one)
ef
(Signature of Owner or Agent) Telephone No PERMIT FEE
Total
No. of Lighting Outlets
No. of Hot fuse
No. of Transformers KVA
Above 0
In a
No. of Lighting Fixtures
Swimming Pool gmd 0
gmd 0
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Burners
FIREALARMS No.ofZone
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices
Heat Total Total
No. of Diposal
No. Pumps
Tons
KW
NO. Of Sounding Devices
NoJ of Self Contained
No. of D' shers
SpacelArea Heating
KW
Detection/Sounding Devk>--s
0 Municipal a Other
No. of D6.
Heating Devices
KW
Local Connection
I I
No. of
No. of
LowVoltage
No. of ftater Heaters KW
Signs
Bailases
Wiring
No. Hydro Massage Tuds
No. of Motors
Total HIP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Lam
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO
have submitted valid proof of same to the Office YES = NO - If you have checked YES please indicate tile " o
Icoverage by checking the appropriate box.
INSURANCE - BOND - OTHER - (PleaseSpecify) '71-eAvel Ere. dS
Estimated Valueof. Electrical Work$. / (Expiration Date)
Work to Start Inspection Date Resquested -Rough Final
Signed under the P nalt' s of perj
FIRM NA =r- ;Fye -,t 4-4-) C -CL a-,,, -L-2,-Ir rit Imr I If, fin
Licensee
Address56 o?-�—Y-kz AW A)
^11thloole I-- — 0 . A.- — �
: am re , e - n S U01-� WOUL 11dVe IFIC IFISLIFRI
General Laws. And that my signature on this permit application waives this requirement.
nce coverage or ITS SUDsTanuai equivarem: as requirea ny Massachusetts
Owner Agent (Please Check one)
ef
(Signature of Owner or Agent) Telephone No PERMIT FEE
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name:
Location:
Ci1y Phone
F-1 am a homeowner performing all work myself.
F-1 I am a sole proprietor and have no one working in any capacity
F� I am an employer providing. workers' compensation for my employees working on this job.
Company name:
Address
City: Phone
insurance Co. Policv #
Company name:
Address
Cily: Phone #:
Insurance Co. Policy * I mni�
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 1
andlor one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify under the pains and penalties of pequry that the information provided above is true and correct
Signature —Date
Print name Phone#
Official use only do not write in this area to be completed by city or town official' Building Dept
FICheck if Immediate response is required Building Dept C] Licensing Board
E] Selectman's Office
Contact person 7 Phone Health Department
Other
FORM WORKMAN'S COMPENSATION
<�\ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT T/DO GASFITTING
(Print or Type)
1�0, AOXV<--�R--, —. Mass.
Building Location-.. ss Owners
�301 AM00VC-Irc. y,p
New E] Renovation E] Replacement E]
Permit #
1�
Occupancy
Plans Submitted: Yes[] No
-P
Installing Company Name BAY STATE GAS COMPANY
Addr�ss 55 MARSTON STREET
LAWRENCE, MA 01840
Upsiness Telephone -687--�1105
Name of I-Icensed Plumber or Gas Fitter _Francis X. Corkery
Check one: Certificate #
Corporation 1862
0 Partnership
0 Firm/Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes R( No El
If you have checked Yes. please Indicate the type coverage by checking the appropriate box.
.1
A liability Insurance policy X Other type of indemnity El Bond El
j(9WNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement.
% Check one:
Signature of Owner or 6We—rs—A`gen—t Owner[] Agent El
I hereby certify that all of the details and information I have submitted (or entered) in abovalqpplication are true and aocu%te to the best of my
knowledge and that all plumbing work and installations performed under the ssu f r this application willj*ln4mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 orthr=di'neg S.
T of Ucense:
Plumber �ignaturdof Ucensed PI r o Gas
I
Title Gasfitter
1
Master Ucense Number 3-145
9Journeyman
----------------
to
MEMO
NOR
-MMI
0
OMNI
NONE
0
an
won
Installing Company Name BAY STATE GAS COMPANY
Addr�ss 55 MARSTON STREET
LAWRENCE, MA 01840
Upsiness Telephone -687--�1105
Name of I-Icensed Plumber or Gas Fitter _Francis X. Corkery
Check one: Certificate #
Corporation 1862
0 Partnership
0 Firm/Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes R( No El
If you have checked Yes. please Indicate the type coverage by checking the appropriate box.
.1
A liability Insurance policy X Other type of indemnity El Bond El
j(9WNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement.
% Check one:
Signature of Owner or 6We—rs—A`gen—t Owner[] Agent El
I hereby certify that all of the details and information I have submitted (or entered) in abovalqpplication are true and aocu%te to the best of my
knowledge and that all plumbing work and installations performed under the ssu f r this application willj*ln4mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 orthr=di'neg S.
T of Ucense:
Plumber �ignaturdof Ucensed PI r o Gas
I
Title Gasfitter
1
Master Ucense Number 3-145
9Journeyman
----------------
to
m
0
f -
Q
W
U)
C,
r
0
0
cc
M
w
i w
5e
d
i
w
CL
ZI
0:
0
cc
w
co
w
cc
w
IL
W
w
0
w
CL
0
C)
cc
w
I
cr
cc
j
0
0
IL
LL
In
?:
z
0
LL
0
w
ta
im
CL
CL
CL
w
X
ul
w
U.
w
i w
5e
d
i
w
CL
ZI
0:
0
cc
w
co
w
cc
w
IL
W
w
0
w
CL